Cyanoacrylate tissue adhesive versus silk sutures for mandibular third molar surgery: a systematic review and meta-analysis

OBJECTIVE

Cyanoacrylate tissue adhesive has been presented as an alternative to sutures and several studies have compared them. The objective of this meta-analysis was to evaluate the effect of cyanoacrylate tissue adhesive on postoperative pain and swelling, following mandibular third molar surgery.

MATERIALS AND METHODS

Database search was conducted in MEDLINE/PubMed and Scopus, along with extensive search in the grey literature, including randomized and non-randomized clinical trials that applied cyanoacrylate adhesive for closing mandibular third molar surgical sites and compared it with silk sutures, assessing postoperative pain and swelling. The search ended on September 22, 2023.

RESULTS

Of 886 identified articles, six were included and meta-analyzed. Applying cyanoacrylate demonstrated a reduction in the overall postoperative pain (SMD = -0.57, 95% CI -1.00 to -0.15, p = 0.009). A similar outcome was noted when pain was evaluated on the first and last postoperative days, based on controlled clinical trials (SMD = -0.47, 95% CI -0.92 to -0.03, p = 0.04), and randomized trials (SMD = -0.97, 95% CI -1.31 to -0.62, p < 0.00001). Patients/sides received cyanoacrylate showed a decrease in postoperative swelling (SMD = -0.26, 95% CI -0.51 to -0.01, p = 0.04). Following the GRADE rating system, the quality of evidence on pain and swelling was judged as moderate and low, respectively.

CONCLUSIONS

The use of cyanoacrylate adhesive may offer benefit in reducing postoperative pain and swelling following mandibular third molar surgery. Nevertheless, this should be further investigated, considering the low number of included reports.

CLINICAL RELEVANCE

The current results could help clinicians who perform this procedure to manage postoperative pain and swelling more effectively.

Can Topical Agents (Arnica and Mucopolysaccharide Polysulfate) Reduce Postoperative Pain, Edema and Trismus Following Mandibular Third Molar Surgery?

BACKGROUND

Postoperative supplemental maintenance following mandibular third molar surgery remains an area of interest.

PURPOSE

Topical agents can modulate inflammatory processes. The aim of the present study was to determine if topical application of arnica or mucopolysaccharide polysulfate (MPSP) reduces pain, trismus, and edema following the removal of impacted mandibular third molars.

MATERIALS AND METHODS

A single center randomized controlled clinical trial was conducted. The patients were randomized into three groups: the control group (standard therapy [ST]: antibiotic + nonsteroidal anti-inflammatory drugs twice a day), the arnica group (arnica + ST), and the MPSP group (MPSP + ST). The patients' pain, trismus, and edema values were measured preoperatively and on postoperative days 1, 3, 5, and 10. Sex, age, and operation time were also included. Analyses included descriptive statistics, analysis of variance, post hoc tests, and determinations of intraclass correlation coefficients. Statistical significance was set at P < .05.

RESULTS

Sixty patients with a mean age of 26.98 ± 10.88 years were included in the study; 55% were females and 45% were males. The mean operation time was 23.8 ± 3.27 minutes. According to the visual analogue scale scores (in centimeter units), the arnica and MPSP groups felt less pain than the control group until day 5 (0.6 ± 0.88, 3.75 ± 1.16, 4.75 ± 1.29, and 1.05 ± 1.10, respectively, for the arnica group; 0.35 ± 0.59, 3.25 ± 1.62, 5.0 ± 1.65, and 1.50 ± 1.32 for the MPSP group; and 1.30 ± 1.17, 5.75 ± 1.37, 7.05 ± 1.10, and 3.15 ± 1.53 for the control group; P < .05). The trismus was lower on days 1, 3, and 5 in the arnica group (-8.05 ± 2.82, -12.15 ± 3.1, and -2.15 ± 1.81, respectively) than in the control group (-12 ± 3.82, -15.65 ± 4.81, and -4±2.81, respectively) (P < .05). The edema was lower on days 1 and 3 in the MPSP group (0.95 ± 2.2 and 1.75 ± 3.7, respectively) than in the control group (2.45 ± 0.9 and 3.6 ± 0.8, respectively) (P < .05). Arnica and MPSP had similar pain-relieving action, but arnica was more effective at reducing trismus, while MPSP was more effective at reducing edema.

CONCLUSIONS

Topical application of arnica or MPSP may have a beneficial effect on relieving pain 5 days after surgery, but arnica was also effective at reducing trismus, while MPSP was also effective at reducing edema. Both arnica and MPSP reduced postoperative sequelae.

Case Report: A Challenging Case of Tetanus Presenting with Headache

Tetanus is a life-threatening infectious neurological condition that has become uncommon due to large-scale immunization campaigns. We describe a rare instance of generalized tetanus presenting with a headache on a tropical island in Malaysia. A 43-year-old woman presenting with headaches and generalized body weakness, which progressed into trismus and neck stiffness. Her medical history indicated a wound on the sole of her foot caused by shattered glass in an unhygienic area, but no tetanus prophylaxis had been administered. The patient was subsequently given immunoglobulin, tetanus toxoid, metronidazole, and sedatives in the recommended dosages. Her neurological condition improved remarkably, but she suffered blood pressure fluctuations due to dysautonomia. She was successfully discharged with complete recovery after 6 months of follow-up. The case demonstrates the significance of appropriate identification and care of tetanus, as well as the lethal effects of untreated wounds in vulnerable patients.

Do blood concentrates influence inflammatory signs and symptoms after mandibular third molar surgery? A systematic review and network meta-analysis of randomized clinical trials

OBJECTIVES

To investigate, through a network meta-analysis, the effectiveness of blood concentrates in reducing pain perception, trismus, and edema after mandibular third molar extraction.

MATERIALS AND METHODS

An electronic search was performed in nine databases to locate randomized clinical trials comparing blood concentrate use after mandibular third molar extraction. Two authors selected and extracted the data independently. The individual risk of bias in the studies was assessed with the RoB v2.0 tool. A network meta-analysis compared postoperative pain and trismus scores after applying different blood concentrates, using the mean difference (MD) as an effect estimate. The GRADE approach assessed the certainty of evidence.

RESULTS

Thirty-one randomized clinical trials were included in the review and 18 in the meta-analysis. Leukocyte- and platelet-rich fibrin (L-PRF) was the most used blood concentrate, followed by platelet-rich plasma (PRP). The network meta-analysis, depending on the analyzed period, evaluated up to 1240 surgeries. Among the analyzed blood concentrates, advanced platelet-rich fibrin (A-PRF) performed better among the analyzed blood concentrates, decreasing postoperative pain in 1, 2, 3, and 7 days and reducing trismus up to the inflammatory peak compared to blood clots. Only two studies had a low risk of bias.

CONCLUSIONS

Based on very low certainty of evidence, using concentrates seemed efficient compared to blood clots in reducing pain and trismus after mandibular third molar surgeries. A-PRF decreased postoperative pain throughout the evaluated time and trismus during the acute inflammatory peak.

CLINICAL RELEVANCE

A-PRF after mandibular third molar extractions performed better among the analyzed blood concentrates and seemed efficient in improving postoperative quality by decreasing inflammatory signs and symptoms.

Effect of time-dependent ibuprofen administration on the post operatory after impacted third molar extraction: a cross-over randomized controlled trial

PURPOSE

To evaluate time-dependent administration of ibuprofen in a lower third molar extraction model.

METHODS

Eleven patients requiring bilateral surgical removal of lower third molars were recruited and randomized into a blinded crossover randomized controlled trial. For 3 days after surgery, the control group was prescribed ibuprofen 400 mg every 8 h. On the other hand, the experimental group received also ibuprofen 400 mg at breakfast and lunch, replacing the dinner intake with a placebo. Pain measurements (Visual Analog Scale from 0 to 10) were recorded at baseline, 24, 48, and 72 h postoperatively. Facial swelling and trismus were also measured at baseline, 24, and 72 h postoperatively.

RESULTS

Postoperative swelling and pain perception did not show significative difference between the control and experimental groups at 24, 48, and 72 h. Trismus was significantly lower in the control group than in the experimental group at 72 h postoperatively (p = 0.008). Rescue medication consumption seemed to be comparable between groups.

CONCLUSION

Eliminating night time ibuprofen might be insignificant for pain control after third molar extraction.

Use of Photobiomodulation to Reduce Postoperative Pain, Edema, and Trismus After Third Molar Surgery: A Systematic Review and Meta-Analysis

PURPOSE

Third molar extraction can cause surgical trauma, which is associated with pain, edema, trismus, and functional limitations. The aim of the present systematic review was to investigate the effects of photobiomodulation (PBM) following the extraction of impacted mandibular third molars.

METHODS

An electronic search was conducted in 10 databases from inception up to October 2021 and the grey literature, with no restrictions regarding language or year of publication. Randomized controlled clinical trials (RCT) were included. Studies that were not RCTs were excluded. Reviewers independently analyzed titles and abstracts, followed by full-text analysis. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The exposure variable was the use of PBM and the outcomes were pain, edema, and trismus. Meta-analysis was performed using a random-effects model. The estimate was calculated considering standardized mean differences (SMD) and respective 95% confidence intervals (CI) obtained for each outcome on the first, second, third and seventh postoperative days. The level of evidence was assessed using the GRADE approach.

RESULTS

The search resulted in the 3,324 records. Thirty-three RCTs were included in the systematic review and 23 of these were included in the meta-analyses. The studies involved a total of 1,347 participants (56.6% female and 43.4% male) between 16 and 44 years of age. A greater reduction in pain was found in the PBM group compared to the control group on the third postoperative day (SMD: -1.09; 95% CI: -1.63; -0.55; P < .001; low certainty). Edema was discretely lower in the PBM group on the second postoperative day (SMD: -0.61; 95% CI: -1.09; -0.13; P < .001; low certainty) and trismus was discretely lower in the PBM group on the seventh postoperative day (SMD: 0.48; 95% CI: 0.00; 0.96; P < .001; very low certainty).

CONCLUSION

The evidence of the effect of PBM regarding the control of pain, edema, and trismus following third molar extractions is low or very low.

Comparison of dexamethasone administration through sublingual and intramuscular routes for evaluation of pain, swelling, and trismus after impacted mandibular third molar surgery-a prospective randomized controlled study

PURPOSE

To compare the efficacy of dexamethasone when administered preoperatively through sublingual and intramuscular routes for evaluating the reduction in pain, swelling, and trismus after removal of impacted mandibular third molar.

METHODS

The study was conducted on patients who required surgical removal of impacted mandibular third molars under local anesthesia. A total of 150 patients were considered for the study who were divided into two groups of 75 patients each. Patients in the sublingual group were administered with 2 ml of dexamethasone 8 mg along with 2 ml of normal saline through sublingual route and patients in the intramuscular group were administered with 2 ml of dexamethasone 8 mg through intramuscular route 1 h before the commencement of mandibular third molar surgery. The subjects of all two groups were evaluated for pain, swelling, and trismus on 1^st, 3^rd, and 7^th postoperative days.

RESULTS

Patients in the sublingual group had significantly less pain and increased mouth opening on 1^st, 3^rd, and 7^th postoperative days when compared to patients in the intramuscular group (P < 0.05), while the amount of swelling in the sublingual group was significantly less only on the 3^rd and 7^th postoperative days when compared to patients in the intramuscular group (P < 0.05). Four patients in the sublingual group consumed one dose of paracetamol 500 mg as a rescue drug on the day of surgery. In the intramuscular group, 9 patients consumed one dose of the same rescue drug on the day of surgery and 11 patients consumed one dose of rescue drug both on the day of surgery and on the 1^st postoperative day.

CONCLUSION

This study concludes that preoperative administration of dexamethasone 8 mg through sublingual route had better efficacy than intramuscular route in controlling pain, swelling and trismus after mandibular third molar surgery.

CYP450 polymorphisms and clinical pharmacogenetics of ibuprofen after lower third molar extraction

PURPOSE

This study hypothesized that drugs accumulate in the bloodstream of poor-metabolizing patients and may have more adverse effects and different pain perceptions and aimed to investigate the influence of CYP450 polymorphisms on acute postoperative pain, swelling, and trismus controlled by ibuprofen (600 mg) in 200 volunteers after dental extraction. In addition, surgical outcomes can determine pain, edema, and trismus and indicate inflammatory reactions after oral surgeries.

METHODS

Genetic sequencing was performed to identify CYP450 polymorphisms and the surgical parameters evaluated: pre and postoperative swelling, trismus, and temperature; self-reported postoperative pain with visual analog scale (VAS); rescue medication consumed; and severity of adverse reactions.

RESULTS

A multiple linear regression model with independent variables [single nucleotide polymorphisms (SNPs), BMI (body mass index), duration, and difficulty of surgery] and dependent variables [postoperative pain by sum of pain intensity difference (SPID), trismus, and swelling] was used for analysis. The duration of surgery was a predictor for pain at 8 h and 96 h after surgery, and BMI was a predictor for both swelling and trismus on the 2nd postoperative day. When evaluating CYP2C8 and C9 genotyped SNPs, it was observed that normal metabolizers showed higher pain levels than the intermediate/poor metabolizers on the postoperative periods as compared with time 0 h. In another analysis, the poor metabolizers for CYP2C8 and C9 presented lower levels of postoperative pain after 8 h and used rescue medication earlier than normal metabolizers.

CONCLUSION

Ibuprofen 600 mg was very effective in controlling inflammatory pain after lower third molar surgeries, without relevant adverse reactions; although in a very subtle way, patients with poor metabolism had higher levels of pain in the first hours, and no longer after 8 h, and used pain relief medication earlier.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov ID (NCT03169127), on March 16th, 2017.

Efficacy of a drug composed of herbal extracts on postoperative discomfort after surgical removal of impacted mandibular third molar: a randomized, triple-blind, controlled clinical trial

OBJECTIVES

This study investigated and compared the effectiveness of a phytotherapeutic drug composed of herbal extracts on postsurgical discomfort after mandibular third molar surgery.

MATERIALS AND METHODS

Eighty-two patients requiring the surgical removal of a mandibular third molar were randomly assigned to receive placebo (group 1), ibuprofen (group 2), and a phytotherapeutic drug (composed of baicalin, 190 mg; bromelain, 50 mg; escin, 30 mg) (group 3). Drugs were administered after tooth extraction twice a day for 5 days. The primary outcome, pain, was evaluated using a visual analogue scale at 2 h, 6 h, 12 h, 24 h, 48 h, and 7 and 10 days after surgery. The secondary outcomes were the changes in maximum mouth opening and facial contours (mm) between baseline and at 24 h, 72 h, and 7 and 10 days after surgery.

RESULTS

Compared to the baseline, all treatments demonstrated an improvement in the primary and secondary outcomes. Moreover, compared to groups 1 and 2, patients in group 3 yielded a significant reduction of the postoperative pain score at 12 h (p < 0.001), 24 h (p = 0.010), and 48 h (p = 0.048) after surgery. The mean reduction of the swelling and trismus was similar between groups.

CONCLUSIONS

The results of this study suggest that a postoperative administration of a phytotherapeutic drug was found to be effective in postoperative pain management after the surgical removal of impacted mandibular third molars.

CLINICAL RELEVANCE

The phytotherapeutic drug composed of herbal extract determined a decrease in the severity of postoperative pain compared to ibuprofen and placebo.

Oral dexamethasone decreases postoperative pain, swelling, and trismus more than diclofenac following third molar removal: a randomized controlled clinical trial

PURPOSE

The aim of this study was to compare the anti-inflammatory potential of two pharmacotherapy protocols based on the parameters of pain, trismus, and swelling, after extraction of third molars.

METHODS

Thirty patients selected with symmetrical impaction of third molars were submitted to surgical procedures in both sides in different times. For one group, dexamethasone was used for 3 days, and for another group diclofenac sodium was also used for the same period. The main variables analyzed were the visual analogue pain scale (VAS), but others were also analyzed such as swelling and trismus, which were submitted to statistical analysis.

RESULTS

The results had no difference regarding the length of procedures (p = 0.986) and the pain in the immediate and 4-h postoperative period (p = 0.723 and 0.541). The rescue analgesic consumption was higher (p < 0.05) when using the protocol with diclofenac sodium. The variables mouth opening (p < 0.05) and swelling (p < 0.05) were significantly better when using the protocol with dexamethasone in the postoperative period.

CONCLUSIONS

Medical protocol with the use of dexamethasone in the postoperative period was more effective in controlling pain, trismus, and swelling, after the extraction of third molars, when compared to diclofenac sodium.

The effect of laser and botulinum toxin in the treatment of myofascial pain and mouth opening: A randomized clinical trial

This study conducted a randomized clinical trial in 15 patients, who sought care at the Dental Clinic of the University of Passo Fundo, in order to compare the use of low-level laser and botulinum toxin in the treatment of myofascial pain and whether they alter the mouth opening of patients with temporomandibular disorder. The patients were divided into two groups: the Laser group received low-level GaAlAs laser, 100mW of power at a wavelength of 830nm in continuous light emission; and the Toxin group received 30U of botulinum toxin type A (BTX-A) in the first session, and 15U after fifteen days. The assessments were performed by measuring pain with Visual Analogue Scale (VAS), and mouth opening with a digital caliper. Data were submitted to Student's t test at 5% significance level. Regarding pain symptoms, the results indicate that groups treated with laser and toxin registered 7U in VAS, at day 5 the scores were 4.75 and 4.86U, respectively. The laser worked faster (day 12) at 2.75U, and the group treated with BTX-A registered 2.86U at day 30. Both therapies investigated were effective in reducing pain, but the effect of low-level laser was faster than the use of BTX-A. Both treatments showed no statistically significant improvement in mouth opening.

Trismus as the first symptom of amyotrophic lateral sclerosis

We report the case of a 75-year-old female who had a trismus as the first, long-lasting and, isolated symptom of ALS. We discuss also therapeutic possibilities.

Cephalic tetanus with left infranuclear facial palsy

We report a case of 11 years old male who developed trismus associated with left infranuclear facial palsy following injury over forehead. Cephalic tetanus was diagnosed. Rarity of the case as well as mild course it ran, though the incubation period was less than seven days, is the reason for this case report.

Evaluation of a muscle relaxant on sequelae of third molar surgery: a pilot study

OBJECTIVE

The aim of this preliminary study was to evaluate the influence of the muscle relaxant tizanidine following third molar surgery on the main variables trismus and pain as well as on swelling.

STUDY DESIGN

Fifty healthy patients participated in this prospective clinical study. The test group received tizanidine (4 mg in the evenings for the first 2 postoperative days) in addition to antibiotic and antiinflammatory medications. Postoperatively, 1 independent investigator performed clinical examinations. Appropriate statistical analysis was used to evaluate data.

RESULTS

There was no statistically significant difference in facial pain and swelling between the two groups. Statistically significant improvement was detected when the groups were compared for mouth opening ability at days one and three.

CONCLUSION

The results of this trial indicate that the influence of tizanidine on trismus, pain, and swelling does not justify prescription of the additional medication.

The selective and non-selective cyclooxygenase inhibitors valdecoxib and piroxicam induce the same postoperative analgesia and control of trismus and swelling after lower third molar removal

We compared the clinical efficacy of orally administered valdecoxib and piroxicam for the prevention of pain, trismus and swelling after removal of horizontally and totally intrabony impacted lower third molars. Twenty-five patients were scheduled to undergo removal of symmetrically positioned lower third molars in two separate appointments. Valdecoxib (40 mg) or piroxicam (20 mg) was administered in a double-blind, randomized and crossed manner for 4 days after the surgical procedures. Objective and subjective parameters were recorded for comparison of postoperative courses. Both agents were effective for postoperative pain relief (N = 19). There was a similar mouth opening at suture removal compared with the preoperative values (86.14 +/- 4.36 and 93.12 +/- 3.70% of the initial measure for valdecoxib and piroxicam, respectively; ANOVA). There was no significant difference regarding the total amount of rescue medication taken by the patients treated with valdecoxib or piroxicam (173.08 +/- 91.21 and 461.54 +/- 199.85 mg, respectively; Wilcoxon test). There were no significant differences concerning the swelling observed on the second postoperative day compared to baseline measures (6.15 +/- 1.84 and 8.46 +/- 2.04 mm for valdecoxib and piroxicam, respectively; ANOVA) or on the seventh postoperative day (1.69 +/- 1.61 and 2.23 +/- 2.09 mm for valdecoxib and piroxicam, respectively; ANOVA). The cyclooxygenase-2 selective inhibitor valdecoxib is as effective as the non-selective cyclooxygenase inhibitor piroxicam for pain, trismus and swelling control after removal of horizontally and totally intrabony impacted lower third molars.

Atypical masticatory muscle myositis in three cavalier King Charles spaniel littermates

This case report describes a novel manifestation of the immune-mediated disease, masticatory muscle myositis. Clinical signs, including difficulty in opening the mouth (trismus), were seen in three of four 12-week-old cavalier King Charles spaniel littermates. Diagnosis was established by 2M immunohistochemistry, supported by characteristic histopathological changes in affected temporal muscle. Treatment using corticosteroids at immune-modifying doses resulted in resolution of clinical signs in all the affected animals. Masticatory muscle myositis should be considered as a differential diagnosis in groups of young dogs with clinical signs of myositis localised to the head.

The Effect of a Single Dose Prednisolone With and Without Diclofenac on Pain, Trismus, and Swelling After Removal of Mandibular Third Molars

PURPOSE

The purpose of this study was to evaluate the effect of a single intramuscular dose of prednisolone and the prednisolone-diclofenac combination on postoperative pain, trismus, and edema after the removal of third molars.

PATIENTS AND METHODS

Forty-five patients who were to undergo surgical removal of lower third molars were studied. Patients were divided into 3 groups. In the first group, each patient was given 25 mg prednisolone intramuscularly immediately after surgery. In the second group, each patient was given 25 mg prednisolone and diclofenac intramuscularly immediately after surgery, and in the third group, each patient was given sterile saline solution as control group. Postoperative pain was evaluated by visual analogue scale on the day of surgery. Facial swelling and trismus were evaluated on postoperative days 2 and 7. ANOVA was used to analyze these data.

RESULTS

Statistical analysis of the data indicated the prednisolone-diclofenac combination suppressed pain intensity in comparison with control (P < .05) at the 6-hour observation. Both the prednisolone and prednisolone-diclofenac combinations suppressed pain at the seventh postoperative hour in comparison with the control (P < .05). The prednisolone-diclofenac combination group also had a smaller loss of opening at postoperative days 2 and 7 in comparison with both the prednisolone and control groups (P < .05). Postoperative swelling was less in both the prednisolone and prednisolone-diclofenac combination groups, as compared with the control group (P < .05) at postoperative day 2. The prednisolone-diclofenac combination group also had a smaller swelling at postoperative day 7 in comparison with both the prednisolone and control groups (P < .05).

CONCLUSION

It was determined that the combination of a single dose of prednisolone and diclofenac is well-suited to the treatment of postoperative pain, trismus, and swelling after dental surgical procedures and should be used when extensive postoperative swelling of soft tissue is anticipated.

Evaluation of acute trismus by MRI: a case report. Bilateral peritonsillar cellulitis

We describe a rare case of a bilateral peritonsillar cellulitis (PTC). The clinical presentation of fever, trismus and odynophagia was consistent with PTC, more evident on the right side; but the presence of bilateral tonsillar swelling and midline uvula confounded the diagnosis. In spite of the throat examination was performed with a great difficulty due to trismus, the T2 weighted fat saturated STIR magnetic resonance imaging (MRI) guided us to make the diagnosis and to start the intravenous antibiotic treatment immediately.

Effects of co-administered dexamethasone and diclofenac potassium on pain, swelling and trismus following third molar surgery

BACKGROUND

The apparent interactions between the mechanisms of action of non-steroidal anti-inflammatory drugs (NSAIDS) and steroids suggest that co-therapy may provide beneficial inflammatory and pain relief in the absence of side effects. The aim of the study was to compare the effect of co-administered dexamethasone and diclofenac potassium (diclofenac K) with diclofenac K alone on the postoperative pain, swelling and trismus after surgical removal of third molars.

PATIENTS AND METHODS

A prospective randomized double-blind study was conducted at the Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Nigeria. A total of 100 patients were randomly allocated to two treatment groups of dexamethasone (prophylactic 8 mg and postoperative 4 mg IV) and diclofenac K (50 mg Oral before and after surgery), and diclofenac K alone (as with first group). The overall analgesic efficacy of the drug combinations was assessed postoperatively by determination of pain intensity using a category rating scale. Facial swelling was measured using a tape measure placed from tragus to gonion to tragus, while interincisal mouth-opening of patients was measured using a vernier calibrated caliper pre-operatively and post-operatively.

RESULTS

Co-administration of dexamethasone and diclofenac K was significantly superior to diclofenac alone for the relief of pain (P < 0.05), and facial swelling up to post-operative 48 hour (P < 0.05). However, there was no significant difference for trismus relief between the two medication protocols (P > 0.05).

CONCLUSION

This study illustrates enhanced effects of co-administered dexamethasone and diclofenac K on short-term post-operative pain and swelling, compared to diclofenac potassium alone in third molar surgery.

Tiagabine May Reduce Bruxism and Associated Temporomandibular Joint Pain

Tiagabine is an anticonvulsant gamma-aminobutyric acid reuptake inhibitor commonly used as an add-on treatment of refractory partial seizures in persons over 12 years old. Four of the 5 cases reported here indicate that tiagabine might also be remarkably effective in suppressing nocturnal bruxism, trismus, and consequent morning pain in the teeth, masticatory musculature, jaw, and temporomandibular joint areas. Tiagabine has a benign adverse-effect profile, is easily tolerated, and retains effectiveness over time. Bed partners of these patients report that grinding noises have stopped; therefore, the tiagabine effect is probably not simply antinociceptive. The doses used to suppress nocturnal bruxism at bedtime (4-8 mg) are lower than those used to treat seizures.

Severe trismus as a complication of cerebrovascular accident: A case report

Spastic hypertonia is a common sequelae after a cerebrovascular accident (CVA) and is a component of an upper motoneuron lesion. Management of spastic hypertonia may involve the use of centrally acting agents, peripheral blockade, and ablative therapies. We report a case of spastic hypertonia leading to severe trismus after CVA that was successfully treated with botulinum toxin type A. Severe trismus is a potentially life-threatening condition that may lead to permanent functional impairment if not promptly diagnosed and treated. Using electromyography for botulinum toxin muscle selection in this case appears to have helped decrease the dose of botulinum toxin given as well as minimize potential side effects.

Effect of muscle relaxants on experimental jaw-muscle pain and jaw-stretch reflexes: a double-blind and placebo-controlled trial

A randomised, double-blind, placebo-controlled three-way cross-over study was performed to investigate the effect of two muscle relaxants (tolperisone hydrochloride and pridinol mesilate) on experimental jaw-muscle pain and jaw-stretch reflexes. Fifteen healthy men participated in three randomised sessions separated by at least 1 week. In each session 300 mg tolperisone, 8 mg pridinol mesilate or placebo was administered orally as a single dose. One hour after drug administration 0.3 ml hypertonic saline (5.8%) was injected into the right masseter to produce muscle pain. Subjects continuously rated their perceived pain intensity on an electronic 10-cm visual analogue scale (VAS). The pressure pain threshold (PPT) was measured and short-latency reflex responses were evoked in the pre-contracted (15% maximal voluntary contraction) masseter and temporalis muscles by a standardised stretch device (1 mm displacement, 10 ms ramp time) before (baseline), 1 h after medication (post-drug), during ongoing experimental muscle pain (pain-post-drug), and 15 min after pain had vanished (post-pain). Analysis of variance demonstrated significantly lower VAS peak pain scores (5.9 +/- 0.4 cm) after administration of tolperisone hydrochloride compared with pridinol mesilate (6.8 +/- 0.4 cm) and placebo (6.6 +/- 0.4 cm) (P=0.020). Administration of pridinol mesilate was associated with a significant decrease in PPTs compared with tolperisone hydrochloride and placebo (P=0.002) after medication, but not after experimental jaw-muscle pain. The normalised peak-to-peak amplitude of the stretch reflexes were not significantly influenced by the test medication (P=0.762), but were in all sessions significantly facilitated during ongoing experimental jaw-muscle pain (P=0.034). In conclusion, tolperisone hydrochloride provides a small, albeit significant reduction in the perceived intensity of experimental jaw-muscle pain whereas the present dose had no effect on the short-latency jaw-stretch reflex.

Stroke-induced trismus in a pediatric patient: long-term resolution with botulinum toxin A

We present a case of prolonged resolution of stroke-induced trismus after botulinum toxin A treatment in a 9 1/2-yr-old boy. The patient had an idiopathic right posterior fossa hemorrhage with resultant spastic quadriparesis, ataxia, dysarthria, and dysphagia. He developed right-sided trismus with only fair response to stretch. Several months after discharge, the patient had worsening trismus with an interincisal distance of only 0.4-0.7 cm and difficulty with oral hygiene and eating. The patient was treated with botulinum toxin A to the masseter muscles with minimal response. Four months later, he received botulinum toxin A to the bilateral masseter and temporalis muscles and to the right medial and lateral pterygoid muscles, with more improvement. His third and last botulinum toxin A treatment was to the bilateral masseter, temporalis, lateral, and medial pterygoid muscles in larger doses. He had an excellent response, maintaining an interincisal distance of 2.5 cm 1 yr later, with significant improvement in speaking and chewing.

[A case of Satoyoshi syndrome complicating marginal gingivitis of the mandible and dislocation of the temporomandibular joint]

Satoyoshi syndrome is a very rare disorder, characterized by progressive painful intermittent muscle spasms beginning in adolescence. Universal alopecia, diarrhea, amenorrhea and bony deformities are also cardinal features of this syndrome. Skeletal abnormalities, such as joint deformity, epiphysial destruction and retarded growth, are observed in approximately half of patients. However, no bony changes have previously been reported in the region of the head. We present here a male patient with Satoyoshi syndrome. Muscle cramps began in the lower extremities when he was 13 years old, and gradually spread. At the age of 17 years, masticatory muscle cramps made it difficult to eat and speak fluently, and were considered a cause of malacia in this patient. Finally, recurrent severe cramps in the masseter muscles caused marginal gingivitis of the mandible, necessitated extraction of the teeth and caused dislocation of the temporomandibular joint. After treatment with dantrolen sodium at doses up to 150 mg/day, painful spasm decreased significantly. Since masticatory muscles can cause significant stress to the teeth and the temporomandibular joint, sufficient attention should be paid to the oral region to avoid complications in patients with Satoyoshi syndrome.

Trismus: aetiology, differential diagnosis and treatment

Trismus is a problem commonly encountered by the dental practitioner. It has a number of potential causes, and its treatment will depend on the cause. This article discusses the primary causes of this condition and the various treatments available.

A pilot study of pentoxifylline in the treatment of radiation-induced trismus

Radiation-induced trismus has a significant impact on the quality of life of patients receiving radiotherapy for head and neck cancers. Pentoxifylline has immunomodulatory activities that downregulate certain cytokines that have been implicated as mediators of fibrogenic reactions after radiation. A pilot study was therefore conducted to evaluate the efficacy of pentoxifylline in the treatment of radiation-induced trismus. Twenty patients with severe trismus (dental gap < or = 25 mm) after receiving radiotherapy for nasopharyngeal carcinoma were enrolled onto the study. Four patients were excluded from analysis because of poor drug compliance. The remaining 16 evaluable patients completed an 8-week course of pentoxifylline at a dose of 400 mg two to three times daily. Changes in dental gap were recorded by measuring the distance between left upper and lower incisor before and after treatment. At the end of treatment, 10 patients had a measured increase in dental gap ranging from 2 to 25 mm. Six patients had an increment of 5 mm or more. The mean dental gap before treatment was 12.5 mm compared with 16.5 mm at the end of treatment (p = 0.023). The mean difference in dental gap was 4 mm, with a 95% confidence interval of 0.6 to 7.4 mm. The drug pentoxifylline appears to exert a modest therapeutic effect in patients with radiation-induced trismus, although our findings need to be confirmed by a randomized placebo-controlled study. While awaiting more evidence from clinical studies, a therapeutic trial of pentoxifylline is worth considering in patients experiencing radiation-induced trismus.

Hemimasticatory spasm associated with localized scleroderma and facial hemiatrophy

OBJECTIVES

To report a case and discuss the mechanism of hemimasticatory spasm.

DESIGN

Case report.

PATIENT

A 37-year-old woman had a 3-year history of involuntary spasms of the right masseter muscle in association with localized scleroderma and facial hemiatrophy. Electrophysiological studies revealed a normal blink reflex. However, the masseter reflex and silent period were absent on the affected side. Distal latency and compound muscle action potential of the masseter nerve were normal. Needle electromyography demonstrated irregular bursts of motor unit potentials similar to those described in hemifacial spasm. A magnetic resonance imaging scan of the head showed mild hypertrophy of the masseter muscle and atrophy of subcutaneous fatty tissues on the affected side. Local injection of botulinum toxin A into the masseter muscle resolved the patient's symptoms.

CONCLUSION

On the basis of clinical and electrophysiological findings, focal demyelination of motor branches of the trigeminal nerve owing to deep tissue changes is suggested as the cause of abnormal excitatory electrical activities resulting in involuntary masticatory movement.

Recurrent steroid-responsive trismus and painful ophthalmoplegia

A 63-year-old woman experienced two episodes of trismus and painful ophthalmoplegia at an interval of six years. She suffered left visual loss, and enhanced CT scan and MR imaging revealed heterogeneous enlargement of the left extraocular muscles extending to the orbital apex. In addition, the left pterygopalatine fossa was filled with a mass isointense with muscle without evidence of surrounding tissue invasion; 67Ga scintigraphy showed high uptake in this lesion. Steroid administration dramatically resolved the trismus, and the mass in the orbit and extraorbit vanished completely. Orbital pseudotumor is characterized by self-limited, relapsing, steroid-responsive painful ophthalmoplegia, and this case could be a variant of this entity with inflammation extending into the extraorbital area.

The effect of intravenous dexamethasone in pediatric adenotonsillectomy

OBJECTIVE

To determine whether the intravenous administration of dexamethasone sodium phosphate before tonsillectomy and adenoidectomy can reduce the morbidity from, and increase the safety of, this procedure.

DESIGN

Prospective, randomized, double-blind, placebo-controlled clinical trial.

SETTING

A university medical center, caring for both ambulatory and hospitalized children.

PATIENTS

Eighty children aged 3 to 15 years undergoing tonsillectomy and adenoidectomy for either chronic tonsillitis or adenotonsillar hypertrophy (obstructive sleep apnea and/or upper airway obstruction).

INTERVENTIONS

Forty-one children received intravenous dexamethasone sodium phosphate (1 mg/kg up to 16 mg) and 39 received placebo before undergoing an electrocautery dissection tonsillectomy and adenoidectomy.

MAIN OUTCOME MEASURES

Postoperative oral intake, pain, vomiting, temperature, and complications.

RESULTS

Patients who received intravenous dexamethasone had significantly less trismus, vomiting, and elevations of temperature 6 hours after surgery and more oral intake (liquids and soft solids) at 24 hours. Three children, all of whom were in the placebo group, had emergency department visits for pain and dehydration. Each group had one child who had a secondary hemorrhage (no surgery needed), one child who had pneumonia, and one child who had night terrors.

CONCLUSIONS

Treatment with intravenous dexamethasone before electrocautery tonsillectomy and adenoidectomy is safe, increases early postoperative oral intake, and decreases morbidity.

Randomized double-blind comparison of tiaprofenic acid and diclophenac sodium after third molar surgery

OBJECTIVE

This study compares the effectiveness of tiaprofenic acid with diclophenac sodium over a 7-day period with respect to pain, facial swelling, and trismus.

STUDY DESIGN

Sixty patients who required general anesthesia for removal of bilateral impacted third molar teeth were included. Intraoperatively, they received intramuscular injections of either tiaprofenic acid or diclophenac sodium followed respectively by tiaprofenic acid tablets for 5 days and placebo for an additional 2 days or diclophenac sodium tablets for the full 7 days. Surgical and anesthetic techniques were standardized. Pain levels were compared hourly for 4 hours postoperatively and thereafter twice daily for 7 days. Changes in facial swelling and trismus were compared on days 2 and 7 postoperatively.

RESULTS

No statistically significant difference was found between the two treatment groups with respect to pain or facial swelling. Only with respect to recovery in mouth-opening ability (trismus) from day 2 to day 7 did diclophenac sodium reveal a statistically significant advantage (p = 0.0452).

Pressurized infusion of sodium hyaluronate for closed lock of the temporomandibular joint. Part I: A case study

Patients with temporomandibular joint disorders (TMD) report a myriad of problems including headaches, facial pain, limited mouth opening capacity, and clicking and/or grating sounds from the temporomandibular joints. Although conservative therapy with an occlusal splint can bring relief for many of these patients, a small number of subjects must be treated by means of surgical procedures. Direct injections of either air or fluids (saline, local anesthetic, corticosteroid, hyaluronate) into the superior and/or inferior temporomandibular joint (TMJ) cavities have gained popularity. The injection of a local anesthetic and hyaluronic acid can provide relief for patients with persistent, painful nontranslatory closed-lock conditions of the TMJs. As documented through objective electronic and computer-enhanced measurements, this case report describes the effect of sodium hyaluronate on a closed lock condition of the TMJ. This case report explains the methodology employed for a larger group of closed lock patients treated and monitored for over one year. The results of that larger group will be reported at a later time after long-term efficacy is confirmed.

Sucralfate in alleviating post-tonsillectomy pain

Tonsillectomy results in severe throat pain, ear pain, and trismus until the exposed and inflamed muscle becomes covered with regenerated mucosa. Sucralfate binds with the fibrinous exudate of duodenal ulcers, forming a protective barrier that promotes healing. If a similar buffer could be created in the tonsillar bed, morbidity may be diminished. A double-blind, randomized study was completed in 34 adult patients to determine whether sucralfate, given four times daily for 10 days as a swish and swallow, would significantly reduce postoperative pain and promote healing and recovery. Sucralfate significantly lowered postoperative throat pain, otalgia, and trismus. Sucralfate is a safe and well-tolerated topical agent that offers significant pain reduction and may promote healing in tonsillectomy patients.

Evaluation of dexamethasone for reduction of postsurgical sequelae of third molar removal

Sixty patients with bilaterally symmetrical impacted third molars participated in this double-blind, within-subject study to quantify the effects of 4 mg of dexamethasone on reducing postsurgical sequelae. Each patient's surgery was staged by mouth side and completed in two appointments 5 to 6 weeks apart. A preoperative dose of dexamethasone given intravenously was randomized to mouth side and surgical appointment; sterile water served as a control. Major areas assessed in this study were facial swelling, pain, and trismus. No difference in swelling and daily pain was noted. However, trismus and global pain were significantly affected by the steroid. Patients had a daily postsurgical increase in incisal opening of 4 to 6 mm over the control side during the examination period. Patients evaluated pain by choosing the least painful side. By a greater than 4:1 margin, patients chose the steroid side as the least painful side. No increase in the rate or type of complications was detected between control and steroid sides.

Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening

Seventeen patients complaining of suddenly occurring, severe, and persistent limited mouth opening were treated by irrigation of the upper compartment of the affected temporomandibular joint with lactated Ringer's solution. This simple treatment was found to be highly effective in reestablishing normal opening and relieving pain for a follow-up period of 4 to 14 months.

Sedation by propofol in tetanus--is it a muscular relaxant?

We investigated the muscular relaxant properties of propofol in a 54 year-old-man with severe tetanus. Four consecutive boluses of propofol 50 mg i.v. were administered. Mean muscular activity recorded on an electromyography (EMG) decreased from 100 to 10-25 mV within 15 s after each bolus. EMG values were restored to prior levels 10 min after the last bolus. Maximum decrease of muscular activity was observed with propofol blood level between 2.90-3.20 micrograms.ml-1. Neuromuscular function recorded by means of evoked electromyography was not affected by propofol administration.

[Temporomandibular injury: a cause of limited mouth opening]

A case of limitation of jaw opening caused by an intentional knife wound to the temporomandibular region is presented. The chief complaint was pain and restricted jaw movement. Treatment consisted of the administration of antiinflammatory agent. Recovery was complete and without complications, normal jaw opening being obtained. The possibility that the inflammatory process stimulates muscular spasm is emphasized.

Analgesic and antiinflammatory effects of glucamethacin (a nonsteroidal antiinflammatory analgesic) after the removal of impacted third molars

A double-blind study was undertaken to compare the effects of glucamethacin, aspirin, and placebo in the control of pain, trismus, and postoperative swelling of 59 outpatients who underwent the surgical removal of impacted lower third molars. Aspirin (1000 mg three times a day) was superior to placebo in one of the analgesic parameters studied, whereas glucamethacin (140 mg three times a day) was not superior to placebo. Both drugs significantly reduced the occurrence of trismus on the day after surgery, but no differences with placebo were found 48 hours postoperatively. In the study of postoperative swelling, no significant differences were found between the medications and the placebo in the postoperative period. It is concluded that glucamethacin, a nonsteroidal antiinflammatory drug, produces a minimal analgesic effect and does not relieve postoperative swelling in the dental patient undergoing surgical removal of impacted third molars.

Relief of pain and trismus in patients treated with naproxen or acetylsalicylic acid after tonsillectomy

The pain-relieving efficacy of naproxen and acetylsalicylic acid (ASA) in tonsillectomized patients was compared in a double blind parallel clinical trial comprising 83 patients, among whom 42 were treated with naproxen and 41 with ASA. The patients were treated post-operatively for two days with either naproxen suppositories 500 mg. twice, or ASA effervescent tablets 1000 mg. three times, daily. The therapeutic gain was evaluated by recording the intensity of pain, reduced ability to open the mouth (trismus), consumption of supplementary analgesic (parcetamol), and pain-related sleep disturbances. The statistical analysis of the results revealed no differences in pain intensity, consumption of additional analgesics or pain-related sleep disturbances in the two treatment groups. A considerable degree of trismus was demonstrated in most of the tonsillectomized patients. This reduced ability to open the mouth was gradually overcome in the naproxen group while it remained unchanged in the ASA group, however, no statistical significant difference could be demonstrated. Additionally, no significant positive correlation between pain intensity and trismus was proven. The pain-relieving effect, however, was unsatisfactory in both the naproxen and the ASA group, and clinical controlled trial studies of alternative analgetics in tonsillectomized patients are still to be encouraged.

Anti-inflammatory effects of ultrasound therapy: evidence for a major placebo effect

The value of therapeutic ultrasound (US) for reducing inflammation was tested in a double-blind controlled study in 150 patients following surgical removal of impacted lower third molars. Facial swelling, trismus, pain and serum C-reactive protein (CRP) were significantly reduced in the US-treated groups and in a placebo group ('mock' US) compared with an untreated control group. The majority of the anti-inflammatory activity was attributable to the placebo effect, and the highest intensity of US (1.5 W.cm-2) was consistently less beneficial than the lower intensities (0.1 and 0.5 W.cm-2) and the mock US.

The anti-inflammatory effects of dexamethasone and therapeutic ultrasound in oral surgery

A single blind, controlled trial was carried out to assess the anti-inflammatory effects of 10 mg dexamethasone given pre- and post-operatively and also ultrasound therapy in patients following the removal of impacted lower third molars. Facial swelling and trismus were significantly reduced in both the dexamethasone- and the ultrasound-treated groups compared with an untreated control group. This first report of the anti-inflammatory properties of ultrasound in a controlled clinical trial indicates its potential clinical use in reducing post-operative morbidity in oral surgery.